Thursday, July 21, 2016

CDC Bemoans Failure to Decrease Overall Alcohol Product Use among Teens, Despite Large Decline in Current Drinking

According to data from the Centers for Disease Control and Prevention (CDC), the prevalence of current drinking among high school students has declined dramatically in the past decade and a half, dropping from 50.0% in 1999 to 34.9% in 2013. One would think that would be cause for celebration. However, the CDC is telling the public that despite this decline in drinking among youth, overall use of alcohol products has stayed the same.

The Office on Alcohol and Health issued a statement yesterday, arguing that the recent declines in youth drinking have been undermined and offset by an increase in the use of new and emerging types of alcohol product use. These products, which look just like traditional alcohol drinks and are consumed in a similar way, threaten the public's health according to CDC because they look like traditional alcohol drinks and are therefore re-normalizing drinking and serving as a gateway to traditional alcohol use.

However, an investigation by The Rest of the Story has revealed that the drinks which CDC is now classifying as "alcohol products" do not actually contain alcohol. In fact, our investigation revealed that these products were created with the specific intention of providing youth with beverages that look like alcohol products and are consumed the same way, but which are much safer because they don't actually contain alcohol.

By submitting a Freedom of Information Act (FOIA) request, we were able to determine that the CDC has rigged the numbers for the past five years by starting to classify alcohol-free beverages as "alcohol products." For example, the CDC now considers Shirley Temples to be alcohol products. Other beverages that the CDC now classifies as alcohol products include alcohol-free spritzers, alcohol-free Sangria, sparkling (non-alcoholic) limeade, and non-alcoholic watermelon/strawberry coolers.

The Rest of the Story conducted an exclusive interview with the CDC about their new classification system. Here are excerpts from the interview:

Rest of the Story: Aren't you pleased with the recent declines in youth drinking? Wouldn't you say that is a public health accomplishment?

CDC: Unfortunately, the dramatic decline in youth drinking of traditional alcoholic beverages has been offset by an increase in youth use of novel alcohol products, such as Shirley Temples and non-alcohol spritzers. Drinking among high school students dropped to the lowest
levels since the National Youth Risk Behavior Survey (YRBS) began in
1991, but the use of other alcohol products, including Shirley Temples, among students poses new challenges.

Rest of the Story: But I don't understand. How can you classify Shirley Temples and other non-alcoholic beverages as "alcohol products" when they don't actually contain alcohol? Isn't that being dishonest, or at least, disingenuous?

CDC: Current drinking is at an all-time low, which is great news.
However, it’s troubling to see that students are engaging in new risk
behaviors, such as drinking Shirley Temples and alcohol-free sangria. We must continue to invest in programs that help reduce
all forms of alcohol use, including Shirley Temples, among youth.

Rest of the Story: But what is the problem with youth drinking alcohol-free beverages? In fact, wouldn't we rather that youth drink alcohol-free beverages than drinks that actually contain alcohol?

CDC: There are concerns that Shirley Temples contribute to normalizing drinking as a social norm and may be a gateway to youth drinking.

Rest of the Story: But isn't the goal to prevent youth drinking of alcohol?

CDC: During 2011–2015, there was no change in current use of any alcohol product among middle and high school students, and in 2015, an estimated
4.7 million U.S. middle and high school students currently used any
alcohol product. As in 2014, Shirley Temples were the most used alcohol product among U.S. middle and high school students in 2015. During
2011–2015, substantial increases in Shirley Temple use among middle
and high school students were reported, resulting in an estimated total
of 3.0 million middle school and high school Shirley Temple users in 2015.
Although youth drinking declined during 2011–2015,
there was no change in use of alcohol products during this time period. Because of increases in the use of
Shirley Temples, no decline occurred
in alcohol use overall during 2011–2015.

Rest of the Story: Isn't there evidence that drinking Shirley Temples is much safer than drinking alcohol-containing beverages?

CDC: Youth use of alcohol in any form is unsafe. For this reason, comprehensive and sustained strategies are needed to
prevent and reduce the use of all alcohol products among youths in the
United States.

Rest of the Story: Is there actual clinical evidence that drinking Shirley Temples is unsafe?

CDC: Despite what many people believe, Shirley Temples are not just pure water. Furthermore, youth consumption of Shirley Temples will re-normalize drinking behavior. Policies to denormalize alcohol use in society and historic
reductions in alcohol consumption may be undermined by this new
'gateway' product.

Rest of the Story: But how can consumption of alcohol-free beverages normalize the drinking of alcohol? Wouldn't that in fact de-normalize alcohol consumption?

CDC: Youth should not use any alcohol product. Moreover, there are other problems with Shirley Temple use. For example, these products may cause former drinkers to relapse to alcohol use. They also may delay the achievement of sobriety among current drinkers. It would be devastating if alcoholics were to substitute Shirley Temples for their drinking instead of quitting alcohol use entirely.

Rest of the Story: Is there anything else you would like to emphasize to the public?

CDC: Yes. Shirley Temples are not just harmless water, as the alcohol industry has been advertising.

Rest of the Story: Thank you for your time.

Recently, the Food and Drug Administration (FDA) promulgated regulations which "deem" alcohol-free beverages like Shirley Temples to be "alcohol products." Restaurants which serve Shirley Temples will now be considered alcohol manufacturers. In addition, other component parts of these beverages will also be regulated as alcohol products, including the glasses they are served in. After consultation with multiple legal experts, The Rest of the Story has confirmed that the cherries that are served with Shirley Temples are also regulated under these alcohol product rules.

We asked the FDA whether this means that companies which sell cherries must submit pre-market alcohol applications (PMAAs) to the agency before they market their cherries. We were referred to the FDA draft guidance, which indicates that cherries will only be regulated if they are part of a "finished alcohol product." This means that companies which sell cherries to restaurants and bars will not have to submit PMAAs. However, if a restaurant incorporates those cherries into a finished alcohol product (e.g., a Shirley Temple), then the restaurant is considered an alcohol manufacturer and will have to comply with the regulations, including the requirement to submit a PMAA.

Despite the concerns of highball glass manufacturers throughout the country, we have confirmed that these companies will not have to submit PMAAs unless they are selling finished alcohol products, meaning a complete Shirley Temple. However, restaurants that prepare their own Shirley Temples will have to conduct safety testing on their highball glasses. In addition, companies that sell pre-made Shirley Temples will be regulated as alcohol manufacturers. Restaurants and bars that sell pre-made Shirley Temple cocktails will not have to comply with the regulations, but those which self-mix the Shirley Temples themselves will have to comply.

Making the PMAA even more burdensome is the FDA's requirement that any variation in the contents of a Shirley Temple require a separate application. This means that restaurants and bars will need separate FDA approval for every different ratio of 7-Up to grenadine that they use in their drinks. Moreover, a separate application will be required for every combination of 7-Up/grenadine ratio and type of glass. Different varieties of cherries will also require separate applications and a separate determination that the Shirley Temple with that particular cherry variety is beneficial for the public's health. That determination must take into account not only the impact of Shirley Temples on individuals who already drink alcohol, but on non-alcohol users who might start drinking Shirley Temples.

One restaurant has filed suit against FDA, arguing that the agency grossly underestimated the number of PMAA submissions that will be required under the regulations. While the FDA estimates there will be only 750 applications, the owner of this restaurant told us that he alone will have to submit 96 separate applications, as they use four different ratios of 7-Up to grenadine, three different types of glasses, four varieties of cherries, and two types of toothpicks.

According to many restaurant owners, the most troubling aspect of the FDA deeming regulations is that they will not be allowed to inform patrons that Shirley Temples are free of alcohol, are safer than real alcoholic beverages, or to even use the term "alcohol-free." For example, restaurants can no longer list Shirley Temples under a menu category of "non-alcoholic beverages." Instead, Shirley Temples will now be lumped in under a general category of "alcoholic beverages," so this menu item will be mixed in with each restaurant's selection of bourbon, fine scotch, rum cocktails, and schnapps.

About Me

Dr. Siegel is a Professor in the Department of Community Health Sciences, Boston University School of Public Health. He has 32 years of experience in the field of tobacco control. He previously spent two years working at the Office on Smoking and Health at CDC, where he conducted research on secondhand smoke and cigarette advertising. He has published nearly 70 papers related to tobacco. He testified in the landmark Engle lawsuit against the tobacco companies, which resulted in an unprecedented $145 billion verdict against the industry. He teaches social and behavioral sciences, mass communication and public health, and public health advocacy in the Masters of Public Health program.